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LUMBAR LAMINECTOMY The Purpose of this Information This information is being provided to you in order to prepare you to make decisions about your own health care. If you should ultimately decide that surgery is the best treatment option for you, this section will help you understand what happens during a decompressive lumbar laminectomy and will help you prepare for your role in the healing and recovery process. Read it thoroughly and answer the questions before making your final decision about your treatment options. The Health Care Team's Role The duty of your health care team is to:
The Patient's Responsibilities You are the only one who can decide to have surgery. It is important that you take ownership of this decision, recognizing the limitations your particular physical condition places on the potential success of each of the treatment options. If you choose to have surgery, your physical condition and your mental attitude will determine your body's ability to heal. You must approach your surgery with confidence, a positive attitude, and a thorough understanding of the anticipated outcome. You should have realistic goals - and work steadily to achieve those goals. The decision to have or not to have surgery includes weighing the risks and benefits involved. You will make the final decision, so ask questions about anything you do not understand. Since medical care is tailored to each person's needs and differences, not all information presented here will apply to the patient's treatment or its outcome. Seek the advice of your physician and other members of the health care team for specific information about the patient's medical condition. Table Of Contents
NOTE: If there is anything you do not understand about the information provided in this book, it is your responsibility to ask a member of your health care team for assistance BEFORE you make your final decision.
The Spinal Column and Vertabrae Your spinal column consists of 24 separate bones, called vertebrae, plus the five fused bones of the sacrum and the four fused bones of the coccyx (often referred to as the "tail bone") (Fig. 1). The vertebrae are stacked one on top of another and can be divided into:
Support for the Vertebral (Spinal) Column
Attached to the vertebrae are muscles, tendons and a group of strong bands, called ligaments. Together, they support the spinal column and help to protect its delicate nerves. The Role of the Vertebral (Spinal) Column Your spinal column enables you to walk upright. It is the central support for your upper body and carries the weight of your head, chest and arms. The vertebrae in the lumbar (or lower back) portion of your spine carry the majority of this weight. The constant pressure from this weight, even when you are simply sitting in a chair, is what usually leads to problems associated with the lower back. The Role of the Invertebral Discs The bony vertebrae of your spinal column are separated from one another by pads of tough cartilage, called intervertebral discs (Fig. 2,above). These discs act like shock absorbers during activity, preventing the individual vertebra from rubbing against one another. Healthy discs, with their gelatin-like inner core, allow the spine to move freely and provide much of the flexibility found in a young person's spine. The Invertebral Disc Nucleus The gelatin-like center of each intervertebral disc (called the nucleus) is surrounded by a tougher, fiber-like outer lining (called the annulus) (Fig. 3). As your body ages, the disc's nucleus begins to dry up and stiffen, increasing the chances that the central bundle of nerves and/or a spinal nerve may eventually become pinched.  The Spinal Canal The spinal cord, which begins at the base of the brain and runs within the spinal canal, ends in the lumbar spine area in a bundle of nerves known as the cauda equina (Fig. 3,above). The spinal canal runs through the center of the spinal column and protects the spinal cord and other delicate spinal nerves. The Spinal Nerve Roots and the Foramen At each vertebral level, a pair of spinal nerve roots branch off from the spinal cord or the cauda equina (Fig 3,above) and pass through an opening in the vertebra called the foramen (Figs. 3,above & 4). "Plump" and healthy discs help to cushion the vertebra and keep the opening of the foramen wide enough for the spinal nerve roots to pass through without being pinched.  The Body's "Electrical" System The spinal nerve roots are part of the body's "electrical" system, carrying "current" (for sensation and movement) to specific parts of the body. These nerves are protected by an "insulated" covering in the same way a "live" electrical line is coated to prevent contact with the bare wire. When a nerve root is damaged, all or part of its protective coating may be rubbed off at the point of injury. Prior to surgery there is no way of telling how much of this "insulation" has been rubbed off or how much damage has been done to the nerve itself (the body's "live electrical wire"). The Body's Aging Process Your body goes through many changes as you get older. You may not see or hear as well as you did when you were younger. We recognize that this is a natural process, and we learn to accept it or make adjustments for it, such as getting glasses or a hearing aid. As your spine ages, it also goes through some natural changes. In a condition often referred to as the Degenerative (or "Aging") Spine, the gelatin-like centers of your discs begin to dry out, causing them to become compressed or "flattened" (Fig.5). This, in turn, causes the vertebrae to"settle." It's one of the reasons most people actually become shorter as they grow older.  The Slowly Closing Window As your disks begin to "compress" and your vertebrae begin to "settle", the window-like openings of the foramen become smaller and smaller (Figs. 5,above & 6,below). Eventually, the opening can become so small that the nerve is "pinched" against a vertebra. It's similar to laying your hand on a window sill. As long as the window is open, there is no problem. However, if someone slowly closes the window, there will be a point at which your hand begins to feel the pressure. The more the window is closed, the greater the pressure and the greater the pain you will feel. The Loss of Your Spine's "Shock Absorbers" At the same time, your aging discs are drying out and losing their ability to act as effective shock absorbers. Your vertebrae begin to bounce against one another and this jarring action actually causes the bone matter of the vertebrae to grow. This results in the formation of bone spurs. The jagged edges of this new growth can cause both the spinal canal and the foramen to become even smaller. When this happens, the result is often the pinching of the cauda equina and/or a spinal nerve root. Symptoms When a spinal nerve is pinched by a narrowing of the foramen, the condition is referred to as lateral recess stenosis. Symptoms include intense pain, numbness and/or weakness in one leg. When the cauda equina becomes compressed by a narrowing of the spinal canal, the condition is referred to as lumbar canal stenosis and the pain, numbness and/or weakness appears in both legs. Individual Preferences If the aging of the spine is a natural process and happens to everyone, why does one person end up with lateral recess stenosis or lumbar canal stenosis while his/her neighbor is seemingly unaffected? The answer is that everyone's spine is unique. Some people are born with discs which are naturally more"plump" than others. Some have wide foraminal or spinal canal openings, while others have narrow ones. These factors as well as your weight, posture and level of physical activity help to determine who will be adversely affected by the aging process. Because the aging of the spinal disks is a natural and irreversible process, treatment options for lateral recess stenosis or lumbar canal stenosis are limited to the following:
When Surgery is NOT an Option: The severity of your symptoms (pain, weakness, numbness) and your general health and physical condition will play an important part in determining when surgery is not an option for you. In general, surgery is not an option when:
When Surgery IS an Option: A decompressive lumbar laminectomy is usually recommended only when specific conditions are met. In general, surgery is recommended when a spinal nerve root(s) is pinched and you have:
The Risks of Having Surgery: Some of the more common risks of having any surgery include excessive bleeding, infection, or a negative reaction to anesthesia. Certain unforeseen circumstances could even lead to death. Clinical experience and scientific calculation indicate that these risks are low, but surgery is still a human effort. You should feel free to ask any questions you have about your specific risk factors. Since a decompressive lumbar laminectomy involves surgery in and around the spine, further nerve damage is a possibility. In some cases, the nerve is already so damaged that the surgical procedure required to simply take the pressure off the nerve could be the "straw that breaks the camel's back." The end result could be numbness, paralysis or a loss of bowel and bladder control. The Risks of Not Having Surgery Without surgery, simple everyday activities also could lead to further nerve damage. The consequences could be much the same as those associated with surgery, including numbness, paralysis or a loss of bowel and bladder control. The Benefits of Having Surgery You can think of surgery as the first step in the healing and recovery process. It can help relieve pressure on your spinal nerve(s) and, thereby, help relieve your leg symptoms. It also may help you begin the process of regaining more normal function in your legs. Your Chances for Success Your level of healing will be determined by your age, your general health and the severity of the damage to your spinal nerve(s). Your attitude and your willingness to work at recovery also will play an important part in your recovery process.
If You Decide to Have Surgery Approach your surgery with a positive mental attitude and with full confidence that you have made the right decision. While the surgeon concentrates on finding and removing the cause of your pinched nerve, you must concentrate on the recovery process. Cooperate fully with your surgeon and focus on the improvements you will make in the future - not on the problems of the past. The Surgeon's Role Your surgeon will:
Your Role You must have a thorough understanding of the diagnosis (what is causing your back or leg symptoms) and the risks and benefits of the proposed surgery. Once you are confident that surgery is the correct option for you, turn your thoughts to the future and the recovery process. Beginning the Operation In the operating room, a decompressive lumbar laminectomy begins with an incision in your lower back (Fig. 6). Through this opening, your surgeon will reach the area where your cauda equina and/or spinal nerve(s) are being pinched.  Reaching the Pinched Nerve After the incision is made, the surgeon will use a retractor to pull aside fat and muscle until the vertebra is exposed. A fine drill is then used to remove a section of the vertebra (dotted lines in Figs. 7,above & 8). Next, an opening is cut in the ligamentum flavum through which the spinal canal can be reached.  Removing the Cause of Pressure Once the spinal nerve root(s) and cauda equina have been exposed, the surgeon will use a fine drill to remove bone spurs or rough edges of the intervertebral disc (Fig.9). This will make the openings of the foramen and the spinal canal larger and help to relieve pressure on your spinal nerves (Fig. 10).  Fusion And Instrumentation On some occasions it may be necessary to stop the movement between two adjacent vertebrae. This is called a fusion. Your surgeon will place bone graft chips between the vertebrae to create a solid section of bone which prevents the motion. The surgeon may also elect to use metal implants (Fig.11) to prevent any motion while the bone graft hardens.  Closing the Incision The operation is completed when each layer of the incision is closed with suture material (stitches) or surgical staples. If the outer incision is closed with staples or non-absorbable sutures, they will have to be removed after the incision has healed.
The Healing and Recovery Process The healing process can begin as soon as the foramen or spinal canal openings have been enlarged and the spinal nerves are no longer being pinched (Fig 10). Healing is the body's natural process of restoring its damaged tissues to a normal, or nearly normal, condition. Healing occurs on its own, but is influenced by such factors as general good health, physical fitness, nutrition and rest. Recovery is the process during which you work at becoming well. You must commit yourself to staying in good health (which means exercising), maintaining a positive mental attitude and following your physician's instructions.  Have Realistic Expectations Recognize that healing and recovery will not happen overnight. It is a process. You may find that much of your progress will be like taking two steps forward and one step "back. "Accept it! And then do all that you can to make sure your steps"forward" are large ones and your steps "backward" are small ones. Be Patient and Persistent During the recovery period in the hospital and at home, try to rebuild your strength gradually. Rest when you feel fatigued but be persistent in your efforts. It is important for you to recognize that we all heal at a different rate. The speed at which you will recover depends in part on your age, your general level of health, your overall physical fitness and your mental attitude. Generally, you will heal more slowly if you are overweight, out of shape or smoke, or if you are a diabetic or have other pre-existing medical problems. Expect Some Pain After Surgery It is normal to have some pain after any operation. After a decompressive lumbar laminectomy, there may be some leg "aching" which occurs as the nerve(s) attempts to heal. You also may feel some muscle spasms across your back and down your legs. And if there was inflammation in the nerve root, you may continue to feel some pain until this inflammation diminishes. You will be given appropriate medication to control your pain, relieve back spasms and reduce inflammation. Be Prepared for Some Emotional Changes It is not unusual to feel tired and discouraged for several days following surgery. These feelings may be your body's natural reaction to the cutback of extra hormones it generated during surgery. Although some emotional letdown can be expected, you must not let it get in the way of your recovery. Don't look back at past problems. It is important for you to look at even the smallest positive steps you make as progress towards your recovery goal. Develop a Positive Mental Attitude You should begin to work on a positive mental attitude even before the surgery is performed. Direct your energies toward the solution of your problem, rather than worrying about what caused your problem. Don't be discouraged by minor setbacks during the recovery process. Concentrate on the progress you make and will continue to make in the future.
Commit to a Healthy Lifestyle Now is the time to commit yourself to a healthier lifestyle. You can begin by taking these important steps: Watch your weight: If you are overweight, you must gradually return to your proper weight. Crash diets rarely work. Commit yourself to better eating habits and stay with them for the rest of your life. Become more active: Your physician will tell you when you can resume normal physical activities after surgery. Make up your mind now that you will develop a regular aerobic exercise routine, such as walking, swimming or riding a bike. However, always check with your physician before starting any exercise program. Going Home from the Hospital In general, hospital stays are becoming shorter, and even though you may feel somewhat uncomfortable at the time you are released, your physician usually will allow you to go home when:
Recovering at Home Once you are at home and you begin to resume your normal activities, follow the guidelines listed below (and contact your physician's office if you have any questions):
Medication You should gradually reduce the amount of pain medication you take. Begin by increasing the amount of time between pills, and then reduce the number of pills taken each time. A certain amount of discomfort can be expected until the swelling goes down and the nerve sensitivity decreases. Substitute moist heat, gentle exercise and short rest periods for pain medication whenever possible. Prevenitive Measures The best way to minimize future problems with your spine is to maintain a healthy lifestyle. It is important that you:
A Patient-Centered Approach This book is provided to help you make an informed decision about your health care. It is an essential part of a patient-centered approach to medicine, called collaboration, in which the health care team (physicians, nurses and technicians), the health care institutions (hospitals, insurance companies, etc.) and the patient's family all work toward achieving the best possible recovery for the patient.  Why the Patient is at the Center Experience has shown that patients who are given the
opportunity to make decisions about their own health care
have less anxiety before their surgery and recover more
quickly after their surgery. Recognize that you have a
right and a responsibility to participate in
the decisions involving your health care.
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